Update on the use of alitretinoin in treating chronic hand eczema

Alitretinoin Compliance in Patients with Chronic Hand Eczema

Background

Oral alitretinoin is effective in the treatment of chronic hand eczema (CHE), and ≥12 weeks of alitretinoin treatment has been shown to be effective in Korean patients. However, in the real world, a considerable number of patients discontinue alitretinoin, which leads to treatment failure.

Objective

To evaluate the compliance rate of alitretinoin treatment and explore common reasons for poor compliance in patients with CHE in the real world.

Methods

We retrospectively reviewed the electronic medical records of CHE patients treated with alitretinoin. We defined ‘poor-compliance’ as subjects who were treated with alitretinoin for <12 weeks and ‘good-compliance’ as subjects who were treated with alitretinoin for ≥12 weeks. We reviewed the demographics, dose, and duration of alitretinoin usage, efficacy, and reasons for poor compliance.

Results

A total of 137 subjects were enrolled, and 77 (56.2%) did not complete the 12-week treatment with alitretinoin. Among them, the non-improvement rate was significantly higher in the poor-compliance group than in the good-compliance group (p<0.01). The main reasons for the alitretinoin cessation in the poor-compliance group were insufficient response (40.8%), followed by high cost (34.7%), and adverse events (24.5%).

Conclusion

Alitretinoin appears the preferred long-term treatment option for CHE. Although there are complaints about late efficacy, cost, and side effects, following proper explanation, these should not justify discontinuation. Physicians need to recognize the reasons for poor compliance with alitretinoin for each patient and suggest continuing alitretinoin for the successful treatment of CHE.

Efficacy of Pumpkin Ointment in Treatment of Chronic Hand Eczema: A Randomized, Active-Controlled, Double Blind Clinical Trial

Background

Hand Eczema (HE) is chronic skin disease with a high prevalence in population. It has negative impact on the quality of life. Due to the public interest in herbal remedies, we attempt to assess the efficacy of pumpkin ointment in treatment of chronic HE in this research.

Methods

This study was conducted in an outpatient clinic at Imam-Khomeini Hospital in Tehran (Iran) from May 2015 to Nov 2016. We performed a double-blind trial on 60 patients with chronic HE randomized to four groups included pumpkin, betamethasone, eucerin and almond ointment (n=15 for each group) for 28 days. Patients were ordered to apply ointments twice a day. Hand Eczema Severity Index (HECSI) and Dermatology Life Quality Index (DLQI) of the patients were evaluated by a dermatologist on the 1st, 14th and 28th d after the start of treatment.

Results

Patients' DLQI scores in pumpkin and betamethasone group was significant and pumpkin group showed a better response in quality of life (P=0.001). Betamethasone and pumpkin ointment were effective and showed significant improvement compared with almond and eucerin and reduce HECSI scores (P=0.002 and P=0.012 respectively). Betamethasone ointment outcome on HECSI scores in comparison with topical pumpkin was significant (P<0.001). No clinically adverse effects were observed.

Conclusion

Although pumpkin ointment showed a better response in patients' DLQI in HE but it was less effective than betamethasone in decreasing HECSI.

Non-genomic effects of nuclear receptors: insights from the anucleate platelet

Nuclear receptors (NRs) have the ability to elicit two different kinds of responses, genomic and non-genomic. Although genomic responses control gene expression by influencing the rate of transcription, non-genomic effects occur rapidly and independently of transcriptional regulation. Due to their anucleate nature and mechanistically well-characterized and rapid responses, platelets provide a model system for the study of any non-genomic effects of the NRs. Several NRs have been found to be present in human platelets, and multiple NR agonists have been shown to elicit anti-platelet effects by a variety of mechanisms. The non-genomic functions of NRs vary, including the regulation of kinase and phosphatase activity, ion channel function, intracellular calcium levels, and production of second messengers. Recently, the characterization of mechanisms and identification of novel binding partners of NRs have further strengthened the prospects of developing their ligands into potential therapeutics that offer cardio-protective properties in addition to their other defined genomic effects.

RXR Ligands Negatively Regulate Thrombosis and Hemostasis

Supplemental Digital Content is available in the text.

Objective—

Platelets have been found to express intracellular nuclear receptors including the retinoid X receptors (RXRα and RXRβ). Treatment of platelets with ligands of RXR has been shown to inhibit platelet responses to ADP and thromboxane A2; however, the effects on responses to other platelet agonists and the underlying mechanism have not been fully characterized.

Approach and Results—

The effect of 9-cis-retinoic acid, docosahexaenoic acid and methoprene acid on collagen receptor (glycoprotein VI [GPVI]) agonists and thrombin-stimulated platelet function; including aggregation, granule secretion, integrin activation, calcium mobilization, integrin αIIbβ3 outside-in signaling and thrombus formation in vitro and in vivo were determined. Treatment of platelets with RXR ligands resulted in attenuation of platelet functional responses after stimulation by GPVI agonists or thrombin and inhibition of integrin αIIbβ3 outside-in signaling. Treatment with 9-cis-retinoic acid caused inhibition of thrombus formation in vitro and an impairment of thrombosis and hemostasis in vivo. Both RXR ligands stimulated protein kinase A activation, measured by VASP S157 phosphorylation, that was found to be dependent on both cAMP and nuclear factor κ-light-chain-enhancer of activated B cell activity.

Conclusions—

This study identifies a widespread, negative regulatory role for RXR in the regulation of platelet functional responses and thrombus formation and describes novel events that lead to the upregulation of protein kinase A, a known negative regulator of many aspects of platelet function. This mechanism may offer a possible explanation for the cardioprotective effects described in vivo after treatment with RXR ligands.

Alitretinoin in Dermatology-An Update

Alitretinoin is a pan retinoic acid agonist. It was initially used as 0.1% gel in the management of localized Kaposi's sarcoma. At present, the use of systemic alitretinoin has proved extremely efficacious in the management of recalcitrant chronic hand eczema. Furthermore, there have been other retinoid responsive dermatosis that have demonstrated remission post usage of systemic alitretinoin. With a better toxicity profile, compared to the other systemic retinoids, alitretinoin could be considered a valuable treatment option in the near future for the treatment of these dermatologic disorders.

Hand dermatitis: an allergist's nightmare

Hand dermatitis is a common skin complaint. We use our hands to explore our environment; subsequently, our hands are in frequent contact with potential allergens and irritants. Patients with hand dermatitis may present to their allergist with this complaint. Approaching the diagnosis and treatment of hand dermatitis can be challenging, as both internal and external factors may contribute to the overall condition. Furthermore, the differential diagnosis of hand dermatitis is broad and the cause often multifactorial. Obtaining a thorough history and performing a focused examination may help the clinician differentiate between multiple causes of hand dermatitis. Numerous treatment options exist for hand dermatitis, and new potential treatments are in development as well. We aim to provide the allergist with a streamlined toolkit for help in the diagnosis and management of hand dermatitis.